Integrated collaborative care intervention for depression and obesity in primary care: translation from research to practice

Meaningful Engagement in Depression and Anxiety Collaborative Care: Associations With Systematic Case Review

BACKGROUND

Collaborative care (CC) is an evidence-based model of care for treating behavioral health conditions in primary care settings. The CC team consists of a primary care provider, behavioral health care manager (CM), and a consultant psychiatrist who collaborate to create treatment plans. To date, there is limited data on factors associated with meaningful engagement in CC programs.

OBJECTIVE

To identify the proportion of patients who were meaningfully engaged and to investigate the factors associated with meaningful engagement in a CC program.

METHODS

Data was collected from a CC program implemented across 27 adult primary care clinics in a Midwestern, U.S. academic medical system. Logistic regression (n = 5218) was used to estimate the odds of receiving meaningful engagement.

RESULTS

Data was collected from 6437 individuals with 68% being female and a mean age of 45 years old (standard deviation 17.6). Overall, 57% of patients were meaningfully engaged; however, this proportion differed based on demographic and clinical factors. Among modifiable clinical factors, systematic case reviews between the CM and psychiatrist (odds ratio: 10.2, 95% confidence interval: 8.6-12.1) and warm handoffs (odds ratio: 1.3, 95% confidence interval: 1.1-1.5) were associated with a higher likelihood of receiving meaningful engagement.

CONCLUSIONS

The presence of systematic case reviews between the behavioral health CM and the consultant psychiatrist was highly associated with meaningful engagement. When implementing such programs, high fidelity to the core principles including regularly scheduled systematic case reviews should be pursued.

Association of Changes in Neural Targets and Dietary Outcomes among Patients with Comorbid Obesity and Depression: Post hoc Analysis of ENGAGE-2 Mechanistic Clinical Trial

BACKGROUND

Disruptions in brain circuits that regulate cognition and emotion can hinder dietary change and weight loss among individuals with obesity and depression.

OBJECTIVE

The study aimed to investigate whether changes in brain targets in the cognitive control, negative affect, and positive affect circuits after 2-mo problem-solving therapy (PST) predict changes in dietary outcomes at 2 and 6 mo.

METHODS

Adults with obesity and depression from an academic health system were randomly assigned to receive PST (7-step problem-solving and behavioral activation strategies) over 2 mo or usual care. Seventy participants (mean age = 45.9 ± 11.6 y; 75.7% women, 55.7% Black, 17.1% Hispanic, 20.0% White; mean BMI = 36.5 ± 5.3 kg/m2; mean Patient Health Questionnaire-9 depression score = 12.7 ± 2.8) completed functional MRI and 24-h food recalls. Ordinary least square regression analyses were performed.

RESULTS

Among intervention participants, increased left dorsal lateral prefrontal cortex (dLPFC) activity of the cognitive control circuit at 2 mo was associated with increased diet quality (β: 0.20; 95% CI: -0.02, 0.42) and decreased calories (β: -0.19; 95% CI: -0.33, -0.04), fat levels (β: -0.22; 95% CI: -0.39, -0.06), and high-sugar food intake (β: -0.18; 95% CI: -0.37, 0.01) at 6 mo. For the negative affect circuit, increased right dLPFC-amygdala connectivity at 2 mo was associated with increased diet quality (β: 0.32; 95% CI: -0.93, 1.57) and fruit and vegetable intake (β: 0.38; 95% CI: -0.75, 1.50) and decreased calories (β: -0.37; 95% CI: -1.29, 0.54), fat levels (β: -0.37; 95% CI: -1.50, 0.76), sodium concentrations (β: -0.36; 95% CI: -1.32, 0.60), and alcohol intake (β: -0.71; 95% CI: -2.10, 0.68) at 2 but not at 6 mo. The usual care group showed opposing associations. The 95% CIs of all between-group differences did not overlap the null, suggesting a significant treatment effect.

CONCLUSIONS

Among adults with obesity and depression who underwent PST compared with those under usual care, improved dLPFC-amygdala regulation of negative affective brain states predicted dietary improvements at 2 mo, whereas improvements in dLPFC-based cognitive control predicted dietary improvements at 6 mo. These findings warrant confirmatory studies. This trial was at clinicaltrials.gov as NCT03841682.